[Dental] Delta Dental Plan Summary

INPPOSUM1123 KR#08314644 Delta Dental PPO™ (Point-of-Service) Summary of Dental Plan Benefits For Group #1151-1001, 1002, 1099 Noblesville Schools This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's allowance for each service and it may vary due to the Dentist's network participation.* Control Plan – Delta Dental of Indiana Benefit Year – January 1 through December 31 Covered Services – Delta Dental PPO™ Dentist Delta Dental Premier® Dentist Nonparticipating Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, cleanings, fluoride, and space maintainers 100% 100% 100% Sealants – to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy – to detect oral cancer 100% 100% 100% Radiographs – X-rays 100% 100% 100% Basic Services Palliative Treatment – to temporarily relieve pain 90% 90% 85% Minor Restorative Services – fillings 90% 90% 85% Endodontic Services – root canals 90% 90% 85% Periodontic Services – to treat gum disease 90% 90% 85% Oral Surgery Services – extractions and dental surgery 90% 90% 85% Other Basic Services – misc. services 90% 90% 85% Major Services Crown Repair – to individual crowns 60% 60% 55% Major Restorative Services – crowns 60% 60% 55% Relines and Repairs – to prosthetic appliances 60% 60% 55% Prosthodontic Services – bridges, implants, dentures, and crowns over implants 60% 60% 55% Orthodontic Services Orthodontic Services – braces 50% 50% 50% Orthodontic Age Limit – through age 18 and under through age 18 and under through age 18 and under * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This amount may be less than what the Dentist charges and you are responsible for that difference.  Oral exams (including evaluations by a specialist) are payable twice per calendar year.  Six prophylaxes (cleanings) are payable per calendar year.  People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her Dentist about treatment.  Fluoride treatments are payable twice per calendar year for people age 18 and under.  Space maintainers are Covered Services without limitation for people age 18 and under.  Bitewing X-rays are payable twice per calendar year and full mouth X-rays (which include bitewing X-rays) or a panorex are payable once in any three-year period.